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Golden Hill Nursing And Rehabilitation Center

99 Golden Hill Drive, Kingston, NY 12401 · For profit - Limited Liability company · 280 certified beds · (845) 340-3390 Medicare & Medicaid certified

Call the home — (845) 340-3390 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent May 2025
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • about 17% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1 Family Practice Dr · (845) 338-6400 · Call to confirm hours
Pharmacy
86 N Front St · (845) 338-8000 · Call to confirm hours
Grocery
Steintex1.0 mi
6 S Prospect St · (845) 853-7041 · Call to confirm hours
Park
RT-214 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.6%14.1%15.4%better
Long-stay residents who lose too much weight3.5%5.8%5.4%better
Long-stay residents with a catheter left in their bladder0.5%0.5%0.9%better
Long-stay residents with a urinary tract infection0.3%1.3%2.0%better
Long-stay residents with depressive symptoms33.0%19.5%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury2.9%3.1%3.3%better
Long-stay residents whose ability to walk worsened8.3%12.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.3%13.2%18.9%better
Long-stay residents given the seasonal flu vaccine96.4%95.3%95.3%typical
Long-stay residents with pressure ulcers3.6%6.5%4.7%better
Long-stay residents with worsening bladder/bowel control17.7%19.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table13.5%13.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.2%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine84.6%78.8%79.4%typical
Short-stay residents rehospitalized after admission17.0%20.6%22.6%better
Short-stay residents with an outpatient ER visit7.6%9.6%12.0%better
Long-stay hospitalizations per 1,000 resident days1.551.701.67typical
Long-stay outpatient ER visits per 1,000 resident days0.981.361.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

50.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 353 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.6%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
73.0%U.S. median 56.6%
Met the expected recovery
0.28U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 73.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 270 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF50.6%CMS range 45.7–55.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 7.0–11.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge73.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge60.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge66.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified96.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.3%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.2%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.1%CMS range 5.8–10.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.421.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.37
RN hours/ resident / day
1.03
LPN hours/ resident / day
1.82
Aide hours/ resident / day
3.22
Total nurse hours/ resident / day
0.18
RN hoursweekends
33.3%
Total nursing turnover
30.8%
RN turnover

How full it usually is: this home is certified for 280 beds and averages 268.9 residents a day — about 96% occupied, or roughly 11 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.22 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.82 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.92 hrs/resident/day on weekends vs 3.33 on weekdays — 12% thinner on weekends. RN hours go from 0.44 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 33% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2025-05-20)
6
at the previous standard inspection (2024-04-16)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · D2026-04-03 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Abbreviated Survey the facility did not ensure the services provided were consistent with professional standards of medication administration that include obtaining physician clarification when the ordered medication could not be dispensed as written prior to administration, for one (Resident #2) of three residents reviewed for medication administration. Specifically, Resident #2 was re-admitted to the facility on [DATE] with a physician's order for Clozapine 100 milligrams, give 1.75 tablet by mouth at bedtime for psychosis. A Pharmacy clarification email provided by the Director of Nursing documented that on 01/16/2026, the pharmacy notified the facility that the medication could not be dispensed as ordered and requested that the physician be contacted to change the order. There was no evidence that the physician was contacted or that a new or clarified order was obtained by facility staff until 01/20/2026. The January 2026 Medication…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-03 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews conducted during the Abbreviated Survey, the facility did not ensure that a resident who was experiencing pain was assessed and provided appropriate and timely pain management, including the timely administration of medications, for one (Resident #3) of four (4) residents reviewed for pain management. Specifically, the Facility Medication Administration Audit Report dated 08/02/2025 through 08/03/2025 documented that Resident #3 was scheduled to have a pain assessment completed at 7:00 PM on 08/02/2025. There was no documentation that the pain assessment was completed as ordered. 2.The 08/02/2025 Medication Administration Audit Report also documented that Resident #3 was scheduled to receive Melatonin 10 milligrams at 8:00 PM and Gabapentin 100 milligrams at 9:00 PM on 08/02/2025. There was no documentation that the medications were administered as ordered, and the Medication Administration Record indicated a signature at 2:10am on 08/03/2025 with reference to nursing progress notes.The findings include: The facility policy titled Pain…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-10-22 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility did not ensure that one (1) of three (3) residents reviewed for blood sugar monitoring and insulin administration received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, Resident #1 had an order placed on admission, 09/24/2025, for 70/30 insulin with no clear order for blood sugar monitoring. Nursing staff inconsistently monitored Resident #1's blood sugar without an order for blood sugar monitoring until one was placed on 10/08/2025. Additionally, the physician notes indicated that Resident #1's blood sugars were being monitored before meals and at hour of sleep from 09/29/2025, but no order was entered until 10/08/2025.Resident #1 had diagnoses that included diabetes, heart failure, and left ankle fracture and repair.The admission Minimum Data Set, dated [DATE] documented Resident #1 had intact cognition, diagnoses included…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-20 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    2) During an observation on 5/14/25 at 12:48 PM Resident #105, #93, #121 were served lunch and began eating. Fourth table mate, Resident #16 was not served lunch until 1:00 PM. Resident #93 verbalized that Resident #16 had not received lunch and repeatedly asked for them to be served. During an interview on 5/15/25 at 12:30 PM Certified Nurse Aide #17 stated they were not aware that all residents at the same table should have been served at the time before moving onto the next table. Unit Manager Registered Nurse #21 stated they were not aware of any residents' concern for everyone to be served at the same time. 10 NYCRR 415.3(d)(1)(i) Based on record review and interviews conducted during the recertification and abbreviated surveys (NY00376199), the facility did not ensure residents were treated in a dignified manor for 3 residents (Residents #1, #3, and #227), reviewed during a staff performance evaluation review, and for 1 resident (Resident #16) reviewed during dining. Specifically, 1) Review of Certified Nurse Aide #4's employment file revealed Residents #1, 3 and 227 were not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-20 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    2) Resident #538 had diagnoses that included metabolic encephalopathy, hypertension, and muscle wasting. The 9/25/2024 admission Minimum Data Set (assessment tool) documented moderately impaired cognition, foley catheter, occasional incontinence of bowel, maximum assistance for toileting hygiene and transfers. The 12/18/2024 Discharge Minimum Data Set documented moderately impaired cognition, foley catheter, incontinent of bowel, dependent on assistance for toileting hygiene and transfers. The Certified Nurse Aide Kardex dated 12/7/24 documented Resident #528 required maximum assistance and was dependent on staff for all ADLs and transfers, except oral and personal hygiene. The September 2024 Documentation Survey Report contained no documented evidence that personal hygiene, toileting hygiene and toilet transfers were completed on 9/24/24 day shift, 9/26/24 evening shift, and 9/21 and 9/25/24 night shift. The October 2024 Documentation Survey Report contained no documented evidence that personal hygiene, toileting hygiene and toilet transfers were completed on 10/4/24 day shift and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-20 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review during the recertification and abbreviated (NY00376199) survey from 05/13/25 through 05/20/25, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, five of five Certified Nurse Aides (#1, #2, #3, #4, #5) did not have a performance review documented at least once every 12 months. The findings include: Policy and Procedure Titled Staff Evaluations dated 1/25 documented the purpose is to establish a consistent and fair process for evaluating the performance of Nursing Home staff to ensure high-quality resident care, compliance with regulations and professional development. A review of 5 Certified Nurse Aide performance reviews noted 5 out of 5 Certified Nurse Aides had no annual performance appraisals in the last 12 months. Certified Nurse Aide #4, with a hire date of 10/24/23, had 14 corrective discipline notices dated 1/11/24 to 5/2/25 in their employment file. The notices included poor customer service, insubordination, failure to follow policy, absenteeism, tardiness,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-20 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview conducted during the recertification and abbreviated (NY00365130) surveys from 5/13/25 to 5/20/25, the facility did not ensure residents were provided food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, a test tray was sampled and found food was not served at a palatable, appetizing temperature; and many residents complained about the food. Findings include: The facility policy titled Meal Delivery documented, meals should be delivered promptly to ensure appropriate temperatures, and all staff is responsible to report any concerns regarding meal temperatures and resident satisfaction. During an interview on 05/13/25 at 10:52 AM, Resident #174 stated the food at the facility is terrible. The vegetables were often undercooked and hard, and the meats were often overdone. The meals came luke warm and alternates were offered but they were not very good either. During interviews on 05/13/25 at 3:27 PM and 05/16/25 at 10:52 AM, Resident #106 stated that they did not like the food at the facility. They…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-20 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews conducted during the recertification survey from 5/13/25 to 5/20/25, the facility did not ensure food was distributed and served in accordance with professional standards for food service safety. Specifically, 1.) On initial kitchen tour, food items were found undated, unsealed, and expired. The handwash sink in food prep area did not work. 2) On follow-up kitchen tour, food temperatures were not at control level on the steam table and dietary staff did not wear proper hair/beard restraint or utilize hygienic practices. 3) The pantry refrigerator on Unit C1 contained undated foods, expired foods and an incomplete temperature log. Findings include: The facility policy Food Receiving and Storage, dated 1/30/24 included documentation that food shall be stored off the floor; all food items will be covered, labeled and dated; refrigerator and freezer temperatures must be monitored and logged; food must be dated and sealed/covered and held no longer than 72 hours. The facility policy Personal Hygiene dated 1/30/24 included documentation that employees…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-20 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interviews during the recertification survey and abbreviated (NY00352562) surveys, the facility did not ensure that an investigation was completed for a resident with an injury of unknown origin for 1 (Resident #489) of 4 residents reviewed for abuse. Specifically, there was no documented evidence an investigation was conducted for Resident #489 with documented bruising on bilateral arms and left hip. The findings are: Resident #489 was admitted to the facility with diagnoses including cerebrovascular accident, non-Alzheimer's dementia, and muscle weakness. The 4/26/24 Minimum Data Set (assessment tool) documented the resident had severely impaired cognition and was dependent on staff with toileting hygiene, needed substantial assistance with shower/bathe self, partial assistance with personal hygiene and chair to bed transfer. The Comprehensive Care Plan, Resident is at Risk for Skin Impairment, last revised on 5/22/24, documented to observe skin redness, swelling or bruising with cares, provide comfort and well-fitting clothing, weekly skin…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review completed during a Recertification survey from 5/13/25-5/20/25 the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #167) of five (5) residents reviewed for Pressure Ulcers. Specifically, Resident #167 who had a Pressure Ulcer and a Chronic Vascular ulcer with Physician ordered dressing changes was not placed on enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities) and staff did not wear proper personal protective equipment (gowns) during care while completing wound dressing changes. The finding is: A Policy and Procedure titled Enhanced Barrier Precautions dated 4/24 stated, the use of gowns and gloves for high-contact resident care activities is indicated for nursing home residents with wounds and or indwelling medical devices. Resident #167 had diagnoses…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Dcited before2025-05-20 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews during the Recertification and Abbreviated (NY00363234) surveys from 5/13/2025-5/20/2025, the facility did not ensure a comfortable and homelike environment by maintaining comfortable sound levels. Specifically, during construction on the South 1 Unit, sounds were not maintained at comfortable levels. Findings included: The Approval for Construction from the Department of Health dated 7/20/2024 documented construction to start on or before 12/2024 and must be completed by 5/1/2025, and project completion by 8/1/2025. An extension was attached and documented a new completion of construction date as November 1, 2025, and project completion date as 2/1/2026. The attached Resident Safety Plan documented that the renovations would occur Monday to Friday 8:00 AM-5:00 PM and Sunday 8:00 AM-5:00 PM. At all times the health, dignity, privacy, and safety of the residents will take precedence over the renovation process. The undated facility Renovation/Construction Policy documented that the facility that must ensure that all renovation…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-20 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record reviews conducted during the recertification and abbreviated (NY00346686, NY00352562) surveys from 5/13/25 to 5/20/25 it was determined that for 1 of 6 residents (Resident #32) reviewed for Accidents, and for 1 of 4 residents (Resident #489) reviewed for Abuse, the facility did not ensure that injuries of unknown origin were reported to the state agency. Specifically, 1) Resident #32 the Department of Health was not notified after the 12/07/24 Accident/Incident Report documented Resident #32 was observed with bruising to their hand and arm, and 2) Resident #489 was documented on 6/24/24 to have bruising to bilateral arms and small area on left hip, and it was not investigated or reported to the Department of Health. The findings include: Policy and Procedure titled Abuse Prevention dated 6/24 documents Reporting/Response - report alleged violations and substantiated incidents to appropriate authorities. 1. Resident #32 with diagnoses of osteoarthritis, bipolar disorder, and dementia. A review of the Quarterly Minimum Date Set (assessment…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the abbreviated survey (NY00377486) the facility did not ensure that the resident, resident's representative(s), or ombudsman was notified of the transfer or discharge, and the reasons for the move, in writing and in a language and manner they understand for 1 (Resident #3) of 3 residents reviewed for discharge. Specifically, Resident #3 was discharged home on 3/13/2025 and there was no documented evidence that the facility provided a notice of discharge at least 30 days before the resident was discharged . a bed hold notice was not provided, the facility did not document discussions with the resident and/or the representative that included information on discharge planning and arrangements for post-discharge care. Additionally, there was no progress notes that documented the reason for discharge, the effective date of discharge, or the location of where the resident will be discharged to. There was no documented evidence that the Managed Long-Term Care were…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews conducted during an Abbreviated Survey (NY00340219), the facility did not ensure residents were free of significant medication errors for 1 (Resident #1) of 4 residents reviewed for Medication Administration. Specifically, on 4/23/24 at 8pm, Licensed Practical Nurse #1 administered Coumadin 2mg to Resident #1 which was put on hold as per Physicians orders on 4/23/24 at 1:24 pm, due to their International Normalized Ratio (INR) being high at 3.3 (normal range 2.0-3.0). Subsequently, Resident #1's International Normalized Ratio (INR) rate increased to 7.9. Resident #1 received 2.5mg of Vitamin K (for prevention of bleeding) immediately. Resident #1's coumadin 2.5mg was discontinued until the International Normalized Ratio (INR) became therapeutic. The Findings are: The undated facility policy titled Medication Errors documented that a medication error is any event that may cause or lead to inappropriate medication use or resident harm. Types of errors include but are not limited to medication that is administered even though it has…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-16 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview conducted during a recertification survey from 4/8/24 to 4/16/24, the facility did not ensure that food was stored in accordance with professional standards for food safety practice, contact and non-food contact equipment and kitchenware were maintained in sanitary condition in accordance with the standards for food service safety. Specifically, leftover foods were unlabeled and labeled foods were expired in the kitchen refrigerator, expired food items were stored on the shelve and dented cans were not separated from good cans, and the milk cooler was full of food particles and debris. The findings include: Observations and interviews from the kitchen tour conducted on 04/08/2024 at 10:45 AM, 04/09/2024 at 9:45 AM and 04/11/2024 between 1:15 PM and 1:25 PM revealed - Expired leftover prunes were found in the refrigerator, with a start date of 04/01/2024 and an intended use-by date of 04/04/2024. Additionally, slices of cake and leftover cucumber salad lacked proper labeling. - Two bottles of kitchen bouquet were discovered to be expired, with one…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-16 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview during the recertification survey conducted from 4/8/24 to 4/16/24, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 5 residents reviewed for indwelling medical devices. Specifically, Residents #230, #38, #198, and #122 had urinary catheters, Resident # 224 had nephrostomy tubes, and enhanced barrier precautions were not implemented. The findings are: The Centers for Medicaid and Medicare Services Quality Safety and Oversight Group documented that Enhanced Barrier Precautions must be implemented on April 1st 2024 for high contact resident care activities for nursing home residents with wounds and indwelling medical devices and for residents with multi-drug resistant organism infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include (but are…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview conducted during the recertification survey from 4/8/24- 4/16/24, the facility did not ensure that the call bell system was accessible for 1 of 35 residents reviewed for environment. Specifically, Resident #133 was observed on two occasions with the call bell system not within the resident's reach. The findings: Resident # 133 was admitted to the facility with diagnoses including mild cognitive impairment, generalized muscle weakness, and hypertension. The 3/4/24 Quarterly Minimum Data Set Assessment documented the resident had intact cognition, required set up assistance with bed mobility and transfers, and required minimal assistance with activities of daily living. On 04/08/24 at 10:44 AM the resident was observed in bed. The call bell cord was observed wrapped on a hook on a wall near the resident's dresser and was not within arm's length of the resident. On 04/09/24 at 09:49 AM the resident was observed in bed. The call bell cord was observed leading from the wall to the floor behind the resident's dresser and was not within…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-16 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review conducted during the recertification survey from 4/8/24 to 4/16/24, the facility did not maintain a safe, clean, and comfortable environment in 2 resident rooms (Room C2-14, and C2-16). Specifically, Room C2-14 had a hole in the ceiling near the resident's bed and damaged ceiling tiles towards the front of the room, and Room C2-16 had large areas of uncovered ceiling where tiles were missing. Findings include: During an observation on 04/08/24 at 12:09 PM, room C2-14 had a large hole in the ceiling above the light fixture near the resident's bed. Water damage was noted around the hole and throughout the ceiling. More water damage was noted to the ceiling near the front of the room. During an observation on 04/09/24 at 09:52 AM, room C2-14 continued to have the large hole in ceiling near the resident's bed and it remained uncovered. The damaged ceiling tiles near the front of the room remained uncovered. During an observation on 04/09/24 at 12:12 PM, room C2-16 had water damage throughout the room. There was a large, uncovered area…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-16 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews during the re-certification survey from 4/8/24 to 4/16/24, the facility did not ensure Minimum Data Set 3.0 comprehensive assessments were completed in a timely manner. Specifically, the annual assessment was not completed within 14 calendar days from admission and/or by the required Assessment Reference Date. This was evident for 1 of 1 resident reviewed for Resident Assessment (Resident #120). The findings are: The facility policy and procedure titled Minimum Data Set 3.0 Policy and Procedure (last revised 5/2023) documented the following: According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the Resident Assessment Instrument specified by the State. An Annual Assessment - completed using an Assessment Reference Date not >366 days from the most recent prior comprehensive assessment and not >92 days from the most recent Quarterly Assessment (counting Assessment Reference Date to Assessment Reference Date). Resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-16 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and staff interview during the recertification survey from 4/8/24 to 4/16/24, the facility did not ensure that appropriate treatment and services were provided to prevent a further decrease in range of motion for 1 of 2 residents (Resident #102) reviewed for position and mobility. Specifically, Resident #102 was observed on two occasions without the blue carrot (or hand roll) in their left hand as ordered. Findings include: Resident #102 had diagnoses including cerebral vascular accident, quadriplegia, and left arm contracture. The quarterly Minimum Data Set (resident assessment tool) dated 12/14/2023 documented the resident had upper and lower extremity impairments on both sides, their cognition was severely impaired, and they were dependent on staff for all activities of daily living. The 6/19/23 Care Plan titled Alteration in Musculoskeletal Status-Severe Osteopenia, at risk for spontaneous fractures without an identifiable or precipitating event, contractures of all extremities. Interventions included to apply blue carrot (or hand roll) in…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-02 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview during an abbreviated survey (NY00300850), the facility did not ensure an area of the facility used by residents was safe for residents to receive services safely and that an equipment was in good repair. Specifically, Resident #1 slipped and fell on the floor while getting water to drink due to an ice machine that leaked and caused moisture on the floor. The findings are: The facility policy titled Resident Safety created 9/2021, and last revised 4/2023 documented residents have the right to live in an environment that promotes safety and well-being. Staff responsibilities included promptly reporting safety concerns and incidents to supervisor. Resident #1 was admitted to the facility with diagnoses that included Alzheimer's disease, anxiety, and hypertension. The Quarterly Minimum Data Set (MDS, and assessment tool) dated 4/16/2022 documented that Resident #1 had severely impaired cognitive skills. The Facility Incident/Accident Investigation Report (A/I) Summary dated 8/3/2022 documented that at approximately 7:40AM Resident #1…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview conducted during an Abbreviated Survey (NY00300850), it was determined that for one (Resident #3) of three residents reviewed for Quality of Care, the facility did not ensure the resident received treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plan. Specifically, (1) medications were not provided to Resident #3 in the form it was ordered and necessary to prevent choking. Resident #3 was on a puree diet and had a crush order for their medications. On 8/18/2023 at 10:50AM the survey team observed Resident #3 in bed with partially dissolved 1 oval pinkish pill on the mattress and 1 round white pill on their abdomen. Facility staff identified the pills as a Diltazem ER 180mg tablet and a Furosemide 40mg or Acetaminophen 325mg tablet; (2) Resident #3 who was diagnosed with Dysphagia (difficulty swallowing) had no Dysphagia Care Plan. The findings are: The facility policy and procedure titled medication Administration created 2/2016, last revised 3/2023 documented…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews conducted during an abbreviated and extended survey (NY00300850), the facility did not ensure that 1 of 3 residents' (Resident #1) environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance to prevent accidents. Specifically, on 8/3/2023 Resident # 1 who was cognitively impaired, required extensive 1-person physical assistance for locomotion on and off the unit, and assessed as high risk for falls slipped and fell by the kitchenette off the dining room. Resident #1 complained of lower back pain post incident and a spinal x-ray dated 8/3/2023 revealed T-12 mild compression fracture of indeterminate acuity. The findings are: The facility policy titled Preventing an Accident/Incident created 2/2020, last revised 4/2023 documented that all reasonable steps are taken to help prevent resident from falls and related injury. Residents will be evaluated for their potential risk for falls to assure…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-31 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that current acceptable professional standard of practice regarding storage of multi-dose insulin injection medication were followed. Specifically, (1) An opened, undated and in use multi-dose Levemir Flex Pen Insulin was observed in a plastic bag, assigned to Resident #195, in the B side medication cart; (2) Review of the facility's portable emergency drug box revealed a pharmacy expiration date of 7/2021 affixed to the box. There were conflicting expiration dates on the box and the content list; and (3) The facility provided no evidence that the box was checked or monitored by the nursing staff to ensure accuracy and to detect expiration of the drugs in order to notify the pharmacy of replacement, discrepancies, or to prevent potential problems. This was evident during review of the facility's medication storage for one of seven facility units (A2 Unit). The findings are: 1. A medication…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-31 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a recertification and Abbreviated survey (NY00264492), the facility did ensure that a resident received the necessary care and services to maintain functional ability. Specifically, 1) one of 5 residents (Resident # 428) reviewed for activities of daily living (ADLs) did not receive consistent physical and occupational therapy as ordered by the physician. The findings are: A complainant reported to the NYS DOH the resident was supposed to receive physical and occupational therapy, but therapy was sporadic. Resident #428 is an [AGE] year-old who was admitted to the facility on [DATE] with diagnoses including Major Depression, Parkinson Disease, Hypertension Heart Disease, and Generalized Muscle Weakness. The resident was not in the facility at the time of the survey investigation. The resident was discharged home from the facility on 10/2/2020. According to the 9/15/2020 admission Minimum Data Set (MDS; a resident assessment and screening tool), the resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-08-31 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, conducted during a recertification survey, the facility did not ensure that facility staff followed proper hand hygiene and gloving technique to prevent cross contamination and the spread of infection. Specifically, (1) cross contamination of wound and wound supplies was observed; and (2) removal of soiled gloves and hand hygiene were not observed during a wound care procedure for 1 of 5 residents (Residents #157) reviewed for pressure ulcer/injury. The findings are: Resident #157 is a [AGE] year-old who was admitted to the facility on [DATE] with diagnoses not limited to Diabetes Mellitus, Major Depression, and Morbid Obesity. According to the 2/2/2021 Annual Minimum Data Set (MDS; a resident assessment and screening tool), the resident had intact cognition, and required extensive staff assistance with activities of daily living (ADLs). The MDS coded the resident at risk for pressure ulcer (PU), and stage 3 PU. Physician Orders dated 8/25/2021 included an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to INFINITE CARE — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.0+1.0 vs chain
Health inspection 2 of 51.5+0.5 vs chain
Staffing 2 of 52.4-0.4 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 7 homes this chain runs (chain average 2.0★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
BERGER, ALEXANDERIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST8%since 06/26/2013
FARBENBLUM, EDWARDIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER67%since 01/01/2018
LEBOVICH, TIBORIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST25%since 06/26/2013
KLEIN, SOLOMONIndividualCORPORATE OFFICERsince 06/01/2020

CMS files one row per role, so the 7 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$42.9M
Net patient revenuemost recent cost report
+13.0%
Operating marginrevenue minus expenses
$6.5M
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 69%Medicare 15%Other / private 16%

This home reported $6.5M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$401per resident / day
operating cost
$12,195per month
≈ monthly operating cost
$461per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NY

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New York Medicaid page.

Typical monthly cost in New York
$15,528/mo
Nursing home (semi-private)
$16,729/mo
Nursing home (private)
$7,110/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 335451. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-20, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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